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BLS-15-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-15
PICO Question:
In cats and dogs in CPA (P), does performing chest compression cycles for an extended period of time (e.g. 5 minutes) (I), compared to 2 minute cycles (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Chest compression quality (depth, leaning, rate), Surrogate marker(s) of perfusion, Survival to Discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
1. Favorable neurologic outcome
2. Survival to discharge
3. ROSC
4. Surrogate markers of perfusion
5. Chest compression quality (rate, depth, leaning)
Domain chairs: Steve Epstein, Kate Hopper; final edit by Jamie Burkitt
Evidence evaluators: Teresa Cheng, Céline Pouzot-Nevoret
Conflicts of interest: None reported
Search strategy: See attached document
Evidence Review:
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Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
High, moderate, low, |
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No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Favorable neurologic outcome, Survival to discharge, ROSC, Surrogate markers of perfusion |
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0 |
N/A |
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Outcome: Chest compression quality |
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1 |
OBS |
0 |
- |
- |
0 |
0 |
+ |
0 |
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In this adult human observational study they identified that chest compression rate was consistent with a single rescuer for up to 3 minutes, however chest compression depth started to significantly diminish at 2 and 3 minutes of chest compressions while there was a linear decrease of 6.6 ± 4.9 mm (p=0.002) over 90 to 180 seconds, representing a 12.1% decay in compression depth during that time. |
Very low |
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5 |
EXP |
0 |
- |
- |
0 |
0 |
+ |
0 |
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5 manikin studies, 2 studies found quality of CC after 1 min were better than after 5 min, one study found, 1 min better than 2 min, one study found no difference over 5 min of continuous CC and one study showed continuous deterioration in CC quality over 10 minutes of continuous compressions |
Low |
PICO Question Summary
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Introduction |
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High quality chest compressions (CCs) are considered essential to successful CPR. The quality of CCs is impacted by the depth of compression, compression rate, and leaning during the recoil phase. There is evidence that the quality of CCs can deteriorate over time due to rescuer fatigue and the current human and previous veterinary CPR guidelines recommend alternating rescuers every 2 minutes.1,2
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Consensus on science |
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For the most critical outcomes of FNO, Survival to discharge, ROSC, and Surrogate markers of perfusion, we identified no studies addressing the PICO question.
Outcome 5: Chest compression quality
For the important outcome of CC quality we found 5 experimental studies and 1 observational study that address the PICO question.3–8 One observational study of CPR in adults with IHCA (very low quality of evidence, downgraded for serious indirectness and serious imprecision, upgraded for dose-response effect) found CC rate was consistent with a single rescuer for up to 3 minutes of CCs; however, CC depth significantly diminished at both 2 and 3 minutes. There was a linear decrease in depth of 6.6 ± 4.9 mm (p=0.002) from 90 to 180 seconds, representing a 12.1% decay in compression depth during that time. Five experimental manikin studies were identified (low quality of evidence, downgraded for serious indirectness and serious imprecision, upgraded for dose-response effect); 2 of these studies found the quality of CCs after 1 minute was better than after 5 minutes. One study found the quality of CCs after 1 minute was better than at 2 minutes and 1 study showed continuous deterioration in CC quality over 10 minutes of continuous compressions with the mean percent of adequate CCs per 30 second interval being < 70% at the 2-minute time point. In contrast, one manikin study found no difference in CC quality over 5 min of continuous CCs.
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Treatment recommendation |
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We recommend the cycles of chest compressions delivered by an individual rescuer not extend beyond 2 minutes in intubated dogs and cats undergoing CPR.(strong recommendation, low quality of evidence)
We recommend that if a rescuer perceives they are becoming fatigued, or if other rescuers perceive inadequate chest compression quality, it is reasonable to change compressors during a cycle while minimizing interruption in chest compressions (< 1 second).(strong recommendation, expert opinion) |
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Justification of treatment recommendation |
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Several experimental studies show diminished chest compression quality between minute 1 and minutes 2-3 of chest compressions in a manikin model, and quality of compressions diminishes greatly when a single rescuer performs 5 or more minutes of continuous chest compressions. While there is also a decline in compression quality from 1 to 2 minutes, data show that compressions must be delivered for 60 seconds before reaching maximal arterial pressures during CPR.9 Thus, the risk of decline in compression quality must be weighed against the potential for longer hands-off time that could result from pausing to change the compressor more frequently. |
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Knowledge gaps |
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The ideal duration of manual, continuous chest compressions before switching rescuers in dogs and cats undergoing CPR is unknown. The ideal duration of chest compression delivery to avoid rescuer fatigue severe enough to compromise chest compression quality may be as short as 1 minute; further research is needed. The onset of rescuer fatigue when performing chest compressions in dogs and cats may be different than that documented in human manikin models and may differ depending on patient size and chest conformation. |
References:
1.Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines: RECOVER clinical guidelines. J Vet Emerg Crit Care. 2012;22(s1):S102-S131. doi:10.1111/j.1476-4431.2012.00757.x
2.Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468. doi:10.1161/CIR.0000000000000916
3.Ock SM, Kim YM, Chung J hye, Kim SH. Influence of physical fitness on the performance of 5-minute continuous chest compression. Eur J Emerg Med. 2011;18(5):251-256. doi:10.1097/MEJ.0b013e328345340f
4.Gianotto-Oliveira R, Gianotto-Oliveira G, Gonzalez MM, et al. Quality of continuous chest compressions performed for one or two minutes. Clin Sao Paulo. 2015;70(3):190-195. doi:10.6061/clinics/2015(03)07
5.Badaki-Makun O, Nadel F, Donoghue A, et al. Chest compression quality over time in pediatric resuscitations. Pediatrics. 2013;131(3):e797-804. doi:10.1542/peds.2012-1892
6.McDonald CH, Heggie J, Jones CM, Thorne CJ, Hulme J. Rescuer fatigue under the 2010 ERC guidelines, and its effect on cardiopulmonary resuscitation (CPR) performance. Emerg Med J EMJ. 2013;30(8):623-627. doi:10.1136/emermed-2012-201610
7.Odegaard S, Saether E, Steen PA, Wik L. Quality of lay person CPR performance with compression: ventilation ratios 15:2, 30:2 or continuous chest compressions without ventilations on manikins. Resuscitation. 2006;71(3):335-340. doi:10.1016/j.resuscitation.2006.05.012
8.Sugerman NT, Edelson DP, Leary M, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation. 2009;80(9):981-984. doi:10.1016/j.resuscitation.2009.06.002
9.Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470. doi:10.1161/hc4501.098926
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